Title: Voices of Fear and Safety Women's ambivalence towards breast cancer and breast health: a qualitative study from Jordan

Transcription

1 Author's response to reviews Title: Voices of Fear and Safety Women's ambivalence towards breast cancer and breast health: a qualitative study from Jordan Authors: Hana Taha Dr. (hanagh@yahoo.com) Raeda Al-Qutob Prof. (raeda@johud.org.jo) Lennarth Nyström Ass. Prof. (lennarth.nystrom@epiph.umu.se) Rolf Wahlström Ass. Prof. (rolf.wahlstrom@ki.se) Vanja Berggren Dr. (vanja.berggren@ki.se) Version: 2 Date: 20 June 2012 Author's response to reviews: see over

2 Dear Dr. Jigisha Patel, We thank you for giving us the opportunity to revise manuscript : Voices of Fear and Safety - Women's ambivalence towards breast cancer and breast health: a qualitative study from Jordan. We thank the referees for their valuable comments that enhanced the quality of our revised manuscript. Kindly find in ANNEX 1 a point-by-point response to the comments of the referees that were addressed in our revised manuscript. Respectfully yours Hana Taha 1

3 ANNEX 1 Reviewer 1: Maggi Banning 1. Comment: Introduction could have focused more on the reasons why there is a gap in understanding in relation to deferred breast health behavior. Response: In the Background /paragraph 4, we referred to a systematic review conducted by Alhurishi et al (2011) to identify the explanatory factors for the delayed presentation of breast cancer in the Middle East. It now reads as follows: There is still a gap of knowledge about the explanatory factors for the delayed presentation of breast cancer in the Middle East. A systematic review by Alhurishi et al (2011) found six studies on the explanatory factors for the delayed presentation of breast cancer in the Middle East and all of them employed quantitative methods [5]. Older age and lower educational level were found to have strong effects in explaining late presentation. Having no family history of breast cancer was found to have moderate effect on breast cancer late presentation. There is a need for qualitative research to obtain a deeper understanding of the problem and to provide data for designing breast health promotion strategies that are culturally sensitive to Jordan. Thus, this study aimed to explore Jordanian women s views and perceptions about breast cancer and breast health. The findings will be used for designing breast health promotion strategies that are culturally sensitive to Jordan. 2. Comment: Do we really need to know that Amman is the capital of Jordan etc. I felt that this was a wasted opportunity to discuss relevant contextual information on breast 2

4 health awareness and issues related to psychological, sociological and culture that may impact on an individual s choice of participating in screening. a) Response: In the Methods/ Setting/ paragraph 2 we removed the description of Amman as the capital of Jordan. It now reads as follows: This study was conducted in four governorates; Amman, Irbid, Karak and Balqa. These four governorates constitute 70% of the total population and demonstrate the socio-cultural texture of the Jordanian society. Amman has a total population of 2.4 million (94% urban dwellers). There are clear socio-economic disparities between Amman s western and eastern parts. West Amman is the affluent side of the city, while East Amman is the underprivileged side of the city. People in the respective parts of the city have different lifestyles, experiences, beliefs, and perceptions [7-9]. b) Response: In the Discussion/ paragraph 9 we wrote about the barriers that were reported in the literature to negatively influence Middle Eastern women s breast health seeking behavior. It now reads as follows: The findings of this study are consistent with previous studies in the Middle East [28, 33-37, 46-52]. Several potential barriers were reported in the literature to negatively influence Middle Eastern women s breast health seeking behaviour, including lack of breast health knowledge, lack of physician s recommendation, fear of cancer, worry about finding a breast tumour, fear of stigma, embarrassment, preference of female health providers, opposition of the husband or other male family members, lack of perceived benefits, perceptions that breast cancer is fatal and not curable, lack of time and lack of accessibility to breast health services 3

5 [33-37, 46-52]. As for religion it was found that it acts as a facilitator in terms of motivating women to take charge of their own health [47] and as a barrier when breast cancer is passively accepted as a test from God [35, 48]. 3. Comment: I was wondering whether accessibility to screening centres was assessed by walking or by car. The authors do not refer to whether the participants had accessibility issues. Response: The references that describe primary health services in Jordan mentioned that the services are well accessed and the estimated average travel time to reach the nearest health centre is 30 minutes without clarifying if this was on foot or by car. However, there is no available data about the accessibility to breast cancer screening services by walking or by car. Thus, we wrote in the Methods/ Setting/ paragraph 5 the latest unpublished data about the mammography services in Jordan indicating that the services are unevenly distributed with higher coverage in urban areas. It now reads as follows: Based on the latest unpublished data from JBCP s operations department about the mammography screening services in Jordan, on May 16 th, 2012 there were 67 functional mammography units in Jordan, three of which were digital. They are unevenly distributed with higher coverage in urban areas; 28 of them are in the public sector, 31 in the private sector, 2 in the Royal Medical Services (RMS), 2 in KHCC and 4 in university hospitals. The mammography units in KHCC and RMS are extensively used, while those in the private and the public sector are underutilized. 4. Comment: Spelling error pg9 cold 4

6 Response: The paragraph in which the wrong spelling occurred was rephrased based on the reviewers comments and the word could was deleted. The paragraph reads now as follows: The research team developed a guide for the FGDs based on a review of the literature. Box 1 shows the FGD guide that included open-ended and appropriate probing questions to encourage spontaneous dialogue among women about their perceptions of breast cancer and their views on early detection examinations. The principal investigator (PI) moderated two pilot FGDs in Arabic with years old Jordanian women, after which the FGD guide was revised to facilitate discussion. We also decided to split the participants by age (20-39 years and years) to overcome the shyness of the younger participants. 5

7 Reviewer 2: Ruth Heisey General suggestions for improvement: I. Comment: I found the presentation of the results somewhat confusing. I admire that you created three general themes but some of the subcategories did not appear to fit and it left the reader confused. Response: The categories were clarified in the revised manuscript to avoid confusing the reader, please see Abstract/ Results and Abstract/Findings. Additionally, they are written clearly now in Box 2 that lists all the themes and categories. It now reads as follows: Results: Three themes were constructed from the group discussions: a) Ambivalence in prioritizing own health; b) Feeling fear of breast cancer; and c) Feeling safe from breast cancer. The first theme was seen in women s prioritizing children and family needs and in their experiencing family and social support towards seeking breast health care. The second theme was building on women s perception of breast cancer as an incurable disease associated with suffering and death, their fear of the risk of diminished femininity, husband s rejection and social stigmatization, adding to their apprehensions about breast health examinations. The third theme emerged from the women s perceiving themselves as not being in the risk zone for breast cancer and in their accepting breast cancer as a test from God. In contrast, women also experienced comfort in acquiring breast health knowledge that soothed their fears and motivated them to seek early detection examinations. II. Comment: Prior to presentation of your results a general brief overview of the literature with respect to: barriers to presentation of asymptomatic women for screening 6

8 and barriers to presentation of women breast symptoms to their health care provider would help contextualize your results. (I am assuming that you did not establish in the women you interviewed whether they had breast symptoms or not. a) Response: The participants in this study had no previous history and no symptoms of breast cancer. In the Abstract/ Methods, it now reads as follows: Methods: We performed an explorative qualitative study with purposive sampling. Ten focus groups were conducted consisting of 64 women (aged 20 to 65 years) with no previous history and no symptoms of breast cancer from four governorates in Jordan. The transcribed data was analysed using latent content analysis. b) Response: In the Methods/ Study population, paragraph 1. It now reads as follows: To maximize information richness, the participants in this study were selected purposively among woman aged 20 to 65 years with no previous history and no symptoms of breast cancer [21-23]. c) Response: Kindly refer back to Reviewer 1: Maggi Banning/ Comment 1/ Response. In the Background/ paragraph 4 we wrote about a systematic review conducted by Alhurishi et al (2011) to identify the explanatory factors of the delayed presentation for breast cancer in the Middle East. 7

9 d) Response: Kindly refer back to Reviewer 1: Maggi Banning/ Comment 2/ Response (b). In the Discussion/ paragraph 9 we wrote about the barriers that were reported in the literature to negatively influence Middle Eastern women s breast health seeking behavior. III. Comment: It seems to me that one of the most significant findings likely more prevalent in the Middle East than in other parts of the world- fear of husband s rejection- was somewhat buried in the text It would be nice to see some supporting quotations in this area. A few findings (I suspect) more unique to the Middle East could be highlighted. (See specific comments). Response: In the Findings/ Fear of the risk of diminished femininity and husband s rejection, we added four quotations about husband s rejection and we reorganized the confirming quotation to come directly after the respective text. It now reads as follows: In all the FGDs, women associated breast cancer with fear of a distorted body image and loss of femininity because it inflicts a body organ that symbolizes femininity and motherhood. A woman who gets breast cancer will be devastated; since losing her breasts means that she is finished as a woman and as a mother (2,2) We, women, care about beauty, and the breast is part of a woman's beauty that she needs to show her husband, isn t it true? So her feeling of inferiority remains regardless of how well her husband deals with her, whether normally or with pity, or helps her or supports her psychological condition, this remains inside us (9, 2) It was a common perception that young women hit by breast cancer suffer more than older ones. The women reasoned that older women have grown-up children who would take care of 8

10 them, while the younger women s children are still too young and thus the younger woman will be more vulnerable if the husband rejects her. I know a young woman who had breast cancer; her husband married her best friend, Poor woman, her children are still young and can t take care of her (6, 2) The women were of the opinion that there are few men who would stand by the wife if she had breast cancer. In all the FGDs, women had observed that men whose wives had been stricken by breast cancer had started looking for other women. They expressed that women in general are repressed in the society and considered by men as dolls. I know a woman who had breast cancer her husband rejected her and married another woman because she lost her femininity (3, 8) In our society a woman is manipulated as a toy, a man whose wife gets inflicted with breast cancer, this hits his masculinity and usually immediately his eyes starts wandering after other women looking for a replacement (6,4) A man hates having a sick wife, he prefers that his wife stays healthy and strong, my neighbour had cancer, her husband and daughters felt sorry for her, however after a while her husband started looking for a new bride (8, 3) On the other hand, in some FGDs, women talked about husbands that supported the wife when she was inflicted with breast cancer. She had chemotherapy and as a result she became bold, her four sons along with their father cut their hair and became bold in solidarity with their mother (6, 6) In one FGD women talked about breast cancer being contagious and narrated about husbands rejecting their wives after they had been diagnosed with cancer because they were afraid they might catch the illness. 9

11 These are viruses or bacteria that start eating the breast and continue to eat the whole body leading to death at the end (4, 2) The husband said that this is a virus, a small organism inside the body which eats from the body, it would be possible that it can be transferred to him and live upon him too (4, 7) 10

12 Reviewer 2: Ruth Heisey Specific comments: 1. Comment: Abstract/ Background: please clarify if the women interviewed had breast symptoms or not. (Impacts whether you are trying to encourage screening or detection maneuvers). Response: Kindly refer back to Reviewer 2: Ruth Heisey/ General suggestions for improvement/ Comment II/ Response (a). In the Abstract/ Methods and in the Methods /Study population/paragraph 1, it is written clearly now that the women interviewed had no breast cancer symptoms. 2. Comment: Abstract/Results: as a test by God and from acquiring knowledge Do you mean, accepting breast cancer as a test by God and having comfort due to their Knowledge and skills? (Confusing as written here and in Findings section) You can t really include the perceived knowledge and skills here as written as you essentially presented that as a barrier to accessing care as written as it results in feeling safe. Response: It is clearly written now in the Findings/ Box 2/ Feeling safe from breast cancer/ Accepting breast cancer as a test from God and in Abstract/Results. It reads as follows now: The third theme emerged from the women s perceiving themselves as not being in the risk zone for breast cancer and in their accepting breast cancer as a test from God. In contrast, women also experienced comfort in acquiring breast health knowledge that soothed their fears and motivated them to seek early detection examinations. 11

13 3. Comment: Abstract/Conclusions: Could be written more clearly e.g. could be better addressed by breast health interventions that emphasize the good prognosis involve breast cancer survivors.catalyze family support to encourage access to health?screening. Response: This is clarified in the Abstract/ Conclusions and in the Conclusions as suggested by the reviewer. It reads now as follows: Conclusions: Women s ambivalence in prioritizing their own health and feelings of fear and safety could be better addressed by designing breast health interventions that emphasize the good prognosis for breast cancer when detected early, involve breast cancer survivors in breast health awareness campaigns and catalyse family support to encourage women to seek breast health care. 4. Comment: Background: second paragraph- the five year survival rate reaches up to 100 percent This is just wrong and misleading. In fact the citation you reference indicates 88% 5-year survival for stage one and 93% for stage 0. (Updated 31/1/2012). Response: In the Background/ Paragraph1, we corrected the statement, it now reads as follows: Early detection of breast cancer makes the treatment more effective which leads to better health outcomes and higher survival rates. The 5-year survival rate reaches 93 and 88 % when breast cancer is detected in its earliest stages 0 and I respectively, compared to 15% in stage IV [2]. 12

14 5. Comment: You need a linkage sentence between paragraph five and six in Background section, then a paragraph on existing data on delay before your methods section. Ideally you could point out variations or delay data specific to the Middle East as well (assuming there is some). Response: This was adjusted as recommended by the reviewer. Kindly refer back to Reviewer 1: Maggi Banning/ Comment 1/ Response. 6. Comment: In Methods section paragraph five: what are your free early detection exams -please define- does this include mammography, CBE? Screening and/ or diagnostic? At what age do you commence screening? Important as you are interviewing younger women and appear to have a younger age of onset of breast cancer in Jordanian women. Response: National guidelines for breast cancer early detection examinations are written in Methods/ Study setting/paragraph 4. It now reads as follows: Although the benefits of breast self-examination (BSE) had not been confirmed indisputably in the literature [11, 12] several studies have indicated that women who regularly practice BSE initially present with smaller tumours that less frequently involve the axillary lymph nodes [13-15]. Hence, the Jordan national breast health guidelines promote breast health awareness to all Jordanian women including a recommendation that women should start practicing monthly BSE from the age of 20 years [16]. This is consistent with the recommendations of the Breast Health Global Initiative (BHGI) for limited resources 13

15 countries [17, 18]. Studies have shown that using clinical breast examination (CBE) and mammography screening for early detection of breast cancer lead to down-staging at the onset of diagnosis and improved odds of survival [19]. In Jordan, CBE is recommended once every 1-3 years in the age group years and annually in women aged 40 and above. Mammography is recommended once every 1-2 years starting from age 40 years and above [16]. 7. Comment: Study design: please state why you chose a qualitative approachessentially rewriting the first line- We chose a qualitative approach to get a deeper understanding Response: This was adjusted based on the reviewer recommendation in the Methods/ Study design. It now reads as follows: In this study we chose a qualitative approach to get a deeper understanding of the women s experiences. We conducted focus group discussions (FGDs) to encourage the group dynamics and to generate collective experiences, views and perceptions about breast cancer and breast health [21]. 8. Comment: Demographics: did you document their religion? Response: We did not document the participants religion. 9. Comment: Data collection: Describe the development of the guide and ideally include it. Was it based on a review of the literature, previous work by the researchers? 14

16 Response: We adjusted Paragraph 1/ in the Methods/ Data collection. We also attached the FGD guide in Box 1. The first part of the paragraph now reads as follows: The research team developed a guide for the FGDs based on a review of the literature. Box 1 shows the FGD guide that included open-ended and appropriate probing questions to encourage spontaneous dialogue among women about their perceptions of breast cancer and their views on early detection examinations. 10. Comment: End of first paragraph under Data collection; typo- cold = could. End of third paragraph took = take. a) Response: The paragraph in which the wrong spelling occurred was rephrased based on the reviewers comments, kindly refer back to Reviewer 1: Maggi Banning/ Comment 4/ Response. b) Response: The spelling mistake took was corrected in Methods/ Data collection/ paragraph 2, the sentence reads now as follows: The FGDs were all audio-taped and an Arabic speaking research assistant attended to observe and take notes. 11. Comment: Ethical considerations: Capitalize Health Research Ethics Committee Response: We adjusted the sentence as suggested by the reviewer. It reads now as follows: Health Research Ethics Committee 15

17 12. Comment: Findings: suggest Feeling safe from breast cancer rather than Feeling safe (Discretionary) Response: We adjusted the third theme as suggested by the reviewer in the Abstract/Results, in the Findings, and in Box 2. It now reads as follows: Feeling safe from breast cancer 13. Comment: Put first quote after first sentence and second quote after second sentence. Then state that this did not appear as prevalent in women from the richer areas-third Sentence/ third quote. (Assuming that is what you mean). Response: We wrote the confirming quotation directly after each statement as suggested by the reviewer in the Findings/ Ambivalence in prioritizing own health /children and family come first. It now reads as follows: Giving priority to children and family above their own health was discussed. Women claimed that if there were enough resources they would take care of their own health, however, when there was limited money, women prioritized their children s needs. If I have money allocated for my health, then my son needs money or my daughter wanted a dress, I would put their requests first and leave my own needs last (4, 1) This did not appear as prevalent in the FGDs with women from more affluent areas. They prioritized their children and family without neglecting their own health. Those women told about their own healthy practices that included diet, sports and seeking periodic screening for breast cancer. 16

18 I do my chores but I try to take care of myself too, I don t forget myself, because we usually pamper our children and forget ourselves (6, 7) In all the FGDs, women perceived their own health value from the perspective of being in charge of taking care of the family, and they mentioned that this was also the perception of their husbands. My health is important, because if something bad happens to me, my whole family will be lost, because the mother is the nerve of life (4, 4) 14. Comment: I don t really understand how the Encouraged to seek breast health care fits here-are you saying that a woman s ambivalence could be impacted by this or that this is a motivator to overcome ambivalence? Please be more specific. Response: In the Findings/Family and social support towards seeking breast health care/ first paragraph, it is clearly written now as follows: In all the FGDs, family and social support appeared to be a motivator that enabled women to overcome their ambivalence towards seeking breast health care. 15. Comment: The reference to not needing to ask husband for permission to go needs context-perhaps the women appreciate his indirect support? Or lack of a previously perceived barrier was in fact supportive for the women-is this new? 17

19 Response: In all the FGDs, women appreciated the encouragement they received from their family and social support network to prioritize their own health, however, they did not express appreciation for the indirect support of not needing to ask for the husband s permission. Instead, they talked about this in a casual manner as a normal behavior except in two FGDs from less privileged areas. In the Findings/ Ambivalence in prioritizing own health/ Family and social support towards seeking breast health care we repositioned the quotes after the statement to which they support. It is now written as follows: In all the FGDs, family and social support appeared to be a motivator that enabled women to overcome their ambivalence towards seeking breast health care. The women experienced and appreciated receiving encouragement from their husbands or their mothers to practice breast health care. They told about older daughters and sons booking the appointment and escorting them to the mammography unit. They also mentioned being reminded by a sister to practice BSE or being accompanied by a neighbour or a friend to go for CBE. My family considers my health first, but for me; my health is one of my priorities but not the first (4, 7) In all the FGDs except two, women commented that they did not feel they needed to ask for permission before seeking breast health care but they informed or consulted or were accompanied by the husband if married or the mother if single. The FGDs in which women felt that they needed the husband s permission prior to seeking breast health care were from less privileged areas. I just tell him I am going to the doctor, he is my husband he has to know, but I don t ask for his permission (4, 8) 18

20 16. Comment: Feeling fear: Position your quotes after the statement to which they support. Response: We repositioned the confirming quotations to directly follow the respective statements as suggested by the reviewer, in the Findings/ Feeling fear of breast cancer/ all the categories within that theme. 17. Comment: Fear of risk of diminished femininity. First quote should be after first sentence then please include supporting quote/s for the comments about men looking for other women as this is very powerful and I expect more unique to Jordan and Middle Eastern countries than the rest of the world. Response: Kindly refer back to Reviewer 2: Ruth Heisey/ General suggestions for improvement/ Comment III/ Response. We repositioned the confirming quotations to directly follow the respective statements as suggested by the reviewer. We added confirming quotations about fear of husband s rejection; husband s looking for other women and fear of transmissibility. 18. Comment: I would also discuss here not only the fear of rejection by the husband but also the apparent lack of knowledge in some husbands with respect to the fear of transmissibility (include virus quote) Response: We wrote about this in the Discussion/ third paragraph. It reads now as follows: On the other hand, women in our study told that some husband s had misconceptions about breast cancer being a transmissible illness. Men s knowledge about breast cancer and their 19

21 attitudes towards their partner s breast cancer screening is context sensitive and largely unexplored in literature. In their qualitative study Flores and Mata (1995) found that Latino males lacked specific knowledge about their spouse s breast and cervical cancer screening, procedures, or recommended frequency of such examinations [30]. They suggested that preventive health measures could be improved by a better understanding of the husbands knowledge base and attitudes towards the wife s health and health seeking efforts. Conversely, in a postal survey conducted by Chamot and Perneger (2002) in Geneva, men were found as knowledgeable about breast cancer and mammography screening as women but had more favorable attitudes toward breast cancer screening than women [31]. 19. Comment: Did you notice a relationship between any demographics; Religion/financial security with respect to women that feared rejection? Response: No; we did not look for a relationship and we had no data about religion. 20. Comment: The second quote here belongs after the discussion on social stigmatization. Response: We moved the second quote that was under Fear of the risk of diminished femininity and husband s rejection and it became now under Findings/ Fear of breast cancer/ Fear of social stigmatization. It now reads as follows: Women in all FGDs told that breast cancer is a taboo subject in Jordan. The women explained that the word cancer by itself is a source of fear that is overstated by the society, which leads 20

22 to it being referred to in people s conversations as that disease. Women experienced that some women try to hide their illness because of fear of being socially stigmatized. A woman inflicted with breast cancer in our society hides having that illness, because breast is a sensitive issue for a woman and because that illness is considered to be vicious (9, 4) Even she herself feels insecure after she has her breast removed, for example if you look at her and talk to her, she thinks that you are looking at the side where her breast was removed (4, 8) In all the FGDs women told that having a mother who had breast cancer might hinder the marriage of her daughters. When some people hear about a mother affected by breast cancer, they think that her daughter is going to be affected by the same disease due to heredity (6, 2) 21. Comment: You need to somehow differentiate the barriers; Lack of knowledge in husbands and physicians as barriers to care and lack of sufficient female physicians as a barrier to care-again I suspect these are more prevalent in Jordan than other countries. 21

23 a) Response: The aim of this study was to explore Jordanian women s views and perceptions about breast cancer and breast health. Hence, we did not organize our findings as barriers and motivators; however we addressed the husband s lack of knowledge as a barrier in the Discussion/ Paragraph 3. Please refer back to Reviewer 2: Ruth Heisey/ Specific comments/ Comment 18/Response. b) Response: We addressed the physicians lack of knowledge and women s preference of female physicians for sex-sensitive tests in the Discussion/paragraph 6. It now reads as follows: Our findings showed that women preferred to have their CBE done by a female health provider. This is consistent with previous literature; Ahmad et al (2001) found that physicians gender plays a role in sex-sensitive examination, such as Pap tests and CBE. The study also recommended enhancing physician-patient interactions for sex-sensitive cancer screening examinations by health education initiatives targeting male physicians and women themselves [38]. Another study by Lurie et al (1993) showed that women are more likely to undergo screening with Pap smears and mammograms if they see female rather than male physicians, particularly if the physician is an internist or family practitioner [39]. In this study women told that their fears towards mammography screening were confirmed by their health care providers. A study by Leslie et al (2003) showed that health education given to women by their health providers is effective in increasing their knowledge about breast cancer and the benefits of screening [40]. 22. Comment: Perceiving themselves as not being in the risk zone for cancer: In all the 22

24 focus groups some women Last quote actually to be displays fear rather than no fear. Response: The last quote was moved in the revised manuscript to be the second quotation in the Findings/ Feeling fear of breast cancer / Apprehensions about breast health examinations. It now reads as follows: Women in all the FGDs discussed fear as a barrier that stopped them from practicing breast health examinations. Women told about avoiding touching their breasts or going for CBE or mammography because they feared finding a lump. Some women expressed that even if they had cancer, they did not want to know. I wish if that happened to me, God forbid, I wouldn't know and die without knowing about it (5, 1) On the other hand, in all the FGDs there were women who perceived that they are at higher risk of breast cancer due to having a personal or a family history of breast lumps or being childless or never having breastfed their children. These women had fear from breast cancer that outweighed their concerns towards screening. They told that they practice breast health examinations to be able to detect the disease at its earliest stages. I am scared, because I had a benign lump before and I did the surgery, now I do self-exam every month to be on the safe side. (3, 2) 23. Comment: Accepting breast cancer as a test by God- reference your quote please. 23

25 Response: This quotation was repeated in more than FGD, hence we now re-wrote it as a statement in the revised manuscript not as a referenced quotation. Under Feeling safe from breast cancer / Accepting breast cancer as a test from God, it now reads as follows: The name of God was present in all the FGDs. In some FGDs women expressed that breast cancer is a test of human patience by God. They explained that they feel that breast examinations are not necessary since the issues of illness, life and death should rather be left to Allah Almighty. Whenever anyone mentioned this it was left without being questioned and it put a lid on the discussion. 24. Comment: Discussion generally very good but would like to see where your work is advancing the literature. Response: Please see the Discussion/last paragraph. It now reads as follows: We expect this work to enrich the literature by providing a better understanding of the Jordanian women s ambivalence towards breast cancer and breast health. Moreover, breast health practices are influenced by the socio-cultural context [35, 46] and the findings of this study will be used by the JBCP to design breast health promotion interventions that are culturally appropriate and specifically tailored to overcome the barriers and catalyse on the facilitators in Jordan. The strength of our study is in its methodology, including: recruitment of a purposively diverse sample that enriched the in-depth exploration of the material from the focus groups; the rigour of coding; the latent thematic development; and the triangulation of researchers. Still, the findings of this study cannot be generalized to all Jordanian or Arabic women. 24

26 25. Comment: Conclusion: activities need I would love to see you include something about the role of the fear of rejection by husbands, the lack of information regarding the (lack of) transmissibility of breast cancer and barriers to accessing care due to lack of female physicians (if in fact true) as these seem to be more important and unique in your population and essential to address to assist Jordanian women in accessing breast screening. Response: We wrote about the fear husband s rejection in the Conclusion section/ first paragraph. We wrote about all the other barriers in the Conclusion / second paragraph. Conclusions now read as follows: Our findings contribute to a better understanding of Jordanian women s views of breast cancer and their breast health-seeking behaviour. Breast health awareness interventions need to address women s fears from breast cancer through emphasizing the good prognosis of the disease when detected early and involving breast cancer survivors to provide a living example of winning the survival battle against breast cancer. Women s ambivalence in prioritizing own health, their fear of diminished feminity and husband s rejection could be changed positively through mobilizing family and social support to encourage women to seek early detection of breast cancer. This study also exposed misconceptions among husbands about breast cancer being contagious and misapprehensions among physicians towards mammography screening. As well there were barriers to women s accessing breast health care due to lack of female physicians. These constrains should be handled to enhance Jordanian women access to breast screening. Recognizing the voices of Jordanian women could contribute to earlier detection of breast cancer and thus to higher survival rates. 25